Research Brief
January 2014
Systematic monitoring of the
voluntary medical
male circumcision scale-up in
Eastern and Southern Africa
(SYMMACS)
Background
Eastern and Southern
Africa continue to bear
the greatest burden of the
global HIV epidemic. In
response to clear evidence
that voluntary medical
male circumcision (VMMC)
can reduce the risk of HIV
transmission in heterosexual men by approximately
60%, numerous countries
in Eastern and Southern
Africa have initiated the
scale-up of VMMC services for adolescent and
adult males. To meet the
demand, the international
community has sought
ways to increase the efficiency of VMMC service
delivery while ensuring
quality of service. This
study, The Systematic
Monitoring of the Voluntary
Male Circumcision Scaleup (SYMMACS), was
designed to assess VMMC
scale-up in four priority countries: Kenya, South
Africa, Tanzania, and
Zimbabwe.
In 2010, an expert committee convened by the WHO
outlined “considerations”
or ways in which efficiency within VMMC programs could be improved,
depending upon applicability in the local context,
while ensuring safety.
For the purposes of this
study, practitioners working
closely with the scale-up
of VMMC in their localities
identified six elements specifically related to surgical
efficiency in high-volume
settings.
Key Findings
Adoption of the six elements
of surgical efficiency of
VMMC service delivery
Results from data collection in 2011 and
2012 indicated that each of the four countries differed in their adoption of the WHO’s
six elements for increasing surgical efficiency in voluntary medical male circumcision
(VMMC).
1. South Africa, Tanzania, and
Zimbabwe demonstrated optimizing
the use of facility space, as measured
by the presence of multiple bays in
the operating theater during 2011
and 2012.
2. South Africa and Zimbabwe adopted the practice of using purchased
pre-bundled supplies and disposable
instruments during both years.
3. Kenya and Tanzania practiced taskshifting, or allowing well-trained clinicians who are not medical doctors
to perform VMMC during both 2011
and 2012.
4. All four countries demonstrated tasksharing, or allowing non-physicians
to conduct certain aspects of the procedure, during both years of data
collection.
5. All four countries implemented the
forceps-guided surgical method in
the majority of cases during both
years.
6. South Africa used electrocautery to
stop bleeding instead of ligaturing
sutures during both 2011 and 2012,
and Zimbabwe demonstrated partial
adoption of this method in 2011 and
full adoption in 2012.
Positive evidence on
quality and safety of
VMMC services
SYMMACS showed that safe, high quality
VMMC can be implemented and sustained
at a larger scale, and demonstrated positive
evidence across the countries on several
points:
• VMMC sites in all four countries universally provided group education
for HIV prevention.
• Kenya, Tanzania, and Zimbabwe
achieved close to 100% HIV testing
and counseling by 2012, whereas
South Africa showed lower percentages, reportedly because clients were
tested offsite and referred by these
facilities for VMMC.
• Quality scores for the surgical portions of the
VMMC package was universally high in all four
countries
• The percentage of sites with a functioning
information system increased between 2011
and 2012.
Areas for improvement of VMMC services
(in two or more countries)
• Systems for registering adverse events were
inadequate.
• Sites often lacked post-exposure prophylaxis
(PEP) and guidelines for administering it onsite.
• There were occasional lapses in the correct
technique used in tying surgical knots. There
was also room for improvement in the correct
maintenance of the surgical field during surgery. Providers tended not to follow the WHO
guidance on a post-operative review of vital
signs and use of protective eye gear.
Areas for improvement of VMMC services
• The total elapsed operating time for VMMC
procedures averaged 23-25 minutes across the
four countries and two years, excluding outliers.
• SYMMACS also yielded data on the median
time spent by the primary provider with the
client, which is particularly important in countries such as South Africa and Zimbabwe that
do not authorize other clinical providers to
perform VMMC.
• The findings clearly demonstrated that tasksharing on suturing and use of electrocautery
reduced the total elapsed operating time as
well as the median time spent by the primary
provider with clients in South Africa and
Zimbabwe.
SYMMACS Aimed To
1. Track the implementation of services and adoption of efficiency elements amidst rapid expansion of program sites and client loads;
2. Monitor quality and safety in the evolving
VMMC programs in each country; and
3. Determine the elements of efficiency most closely related with increased productivity.
Six Elements Specifically Related
to Surgical Efficiency in
High-Volume Settings
• Optimizing the use of facility space
• Pre-bundling of supplies and instruments
• Task-shifting (allowing well-trained clinicians
who are not medical doctors, labeled herein as
“other clinical providers,” to perform VMMC)
• Task-sharing (allowing other clinical providers
to conduct certain aspects of the procedure)
• Use of electrocautery/diathermy instead of
ligaturing sutures
• Use of the forceps guided surgical
methodabsence of efficiency elements at the
site, and related data
Recommendations
Results from the SYMMACS evaluation revealed certain areas in need of improvement VMMC programs
in the four target countries. VMMC programs should
consider the following recommendations:
Adoption of efficiency elements
• Work toward change in the national policy
in South Africa and Zimbabwe that currently
prohibits task-shifting.
• Provide more systematic training of other
clinical providers to assist in various aspects of
the procedure (e.g., administering local anaesthesia and completing interrupted sutures).
• Consider expanding the use of electrocautery
in Kenya and Tanzania, if appropriate given
local conditions.
• Encourage the more widespread use of purchased pre-bundled kits with disposable
instruments in Kenya and Tanzania.
Adoption of efficiency elements
Findings highlighted the importance of ongoing monitoring, evaluation, and quality assurance for these
programs, specifically:
• Effective monitoring and reporting of adverse
events: Train personnel in the use of consistent
definitions to classify adverse events; improve
staff performance in consistently screening
for, recording, and reporting adverse events,
especially severe adverse events; and provide
external monitoring of this process.
• Supervision: Establish a system of regular
supervisory visits to each VMMC site, including supervision of adverse events registration.
• Training: In training of primary providers, place
particular emphasis on techniques or steps that
caused difficulty to some providers in some countries, such as:
ºº Currently identifying skin to be excised
ºº Safe administration of local anesthesia
ºº Using the correct technique to tie the surgical
knot
ºº Correctly aligning the frenulum and placing the
secure mattress suture.
ºº Protocols and guidelines: Ensure that key guidelines are available at or near operating theatre.
Conclusion
Study Methods & Design
The SYMMACS study consisted of two rounds of
cross-sectional data collection during 2011 and 2012.
Seventy-three VMMC facilities were selected for
assessment across the four countries in 2011, and 122
in 2012 (sampling was designed to accommodate new
facilities that became operational in 2012).
Data was collected during two-day visits to each
VMMC site, supplemented by data from existing
health information systems. Data were collected
using four instruments:
• A quality-assessment of the VMMC site (a
shortened version of the WHO assessment tool
for this purpose)
• Observation of up to 10 VMMC procedures
per site, including timing of each operation
• Interviews with the primary and secondary
VMMC service providers
• Compilation of monthly data on number of
operations, rate of adverse events, presence/
absence of efficiency elements at the site, and
related data
The SYMMACS study included the in-depth examination and documentation of the actual implementation
of VMMC service delivery over a two-year period in
key countries. Results offer insight into common trends
across countries as well as country-specific strengths
and weaknesses. SYMMACS is the first study to provide
data on the implementation of VMMC programs and
adoption of elements of surgical efficiency. Findings
have already had demonstrable effects including a policy change on task-shifting in Zimbabwe, a review of the
monitoring system for adverse events specifically and M&E and QA generally in South Africa, a shift towards
increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service
delivery in Kenya.
Acknowledgements
The study was implemented by USAID | Project SEARCH, Task Order No.2, which is funded by the U.S. Agency for International
Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency
Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by
the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP) in collaboration with Tulane University
School of Public Health and Tropical Medicine.
Systematic monitoring of the voluntary medical male circumcision scale-up in Eastern and Southern Africa (SYMMACS):
Interim report on results from Kenya, South Africa, Tanzania and Zimbabwe.
October 2012. Baltimore: USAID | Project Search: Research to Prevention.
Available: www.jhsph.edu/r2p. The Johns Hopkins University. 111 Market Place, Suite 310. Baltimore, MD 21202